Essay: Evidence based practice (EBP)

Evidence based practice (EBP) is the process of collecting, processing and implementing research findings in order to improve clinical practice, patients’ outcomes, or the work environment. Applying the EBP approach to nursing practice assists us to provide the highest quality and most cost effective patient care possible, nursing interventions should be methodological, practical decisions that are made based on EBP research studies (Chrisman et al., 2014). One of the main features of EBP is the reliance on the partnership of hard scientific evidence, clinical expertise and individual patient choices and needs, moreover it is spreading popularity in many health care disciplines including social work and psychology (McKibbon, 1998). Effective EBP involves five crucial steps and takes both time and energy. The first step is to formulate the question that needs to be answered in order to satisfy the needs of the health care or needs of a specific patient. The second step is the process of retrieving the information necessary to answer the question, reading and assessing this information assists with making a clinical decision which in turn forms the third step. The fourth step is to execute the decision and the fifth and final step is the evaluation of the process in order to determine if optimal outcomes have been achieved for both the patient and the health care system (McKibbon, 1998). Evidence based practice demands more practice relevant research, closer working relationships between clinicians and researchers and also changes in the education of students, whilst providing opportunities for nursing care to be more individualised, much more effective, dynamic and streamlined and maximising effects of clinical judgement. When evidence is used as a means of defining best practices as opposed to supporting existing practices, nursing care is able to keep pace with the latest technological advances whilst taking advantage of new knowledge developments (Youngblut and Brooten, 2001).
Care pathways are a set of management guidelines, usually in the form of a flow chart, which can be applied to a group of patients who have the same condition. It is a tool that identifies a recognised best practice approach based on evidence based healthcare, at certain stages of a disease or condition in order to improve quality of care (Best Practice Journal, 2012). Care pathways have been described as a complex intervention for the decision making and organisation of care processes for a well-defined group of patients during a well-defined period (Vanhaecht, De Witte and Sermeus, 2007). However, the likelihood is that many people with a diagnosis of dementia may be living with one or more long term conditions (National Housing Federation, 2015). Developed in the 1980’s, the aim of a care pathway is to enhance the quality of care across the continuum by improving risk adjusted patient outcomes, increasing patient satisfaction, promoting patient safety and optimizing the use of resources (Schriivers, van Hoore and Huiskes, 2012).
Care pathways will systematically map out a care journey that an individual can expect, it will cross organisational boundaries, be multi-professional and act as a prompt for care. They also require consistent documentation which provides the basis for ongoing audit (Social Care Institute for Excellence, 2014). One study carried out, exploring the perspectives of health care professionals involved in the transition process to a care pathways approach found that professionals agreed that care pathways led to an increase in communication, with increased access to other professionals and improved input and discussion. Professionals also identified an increased understanding of the roles of different professionals and improved interdisciplinary relationships, furthermore the need for clear leadership in order to facilitate the care pathway approach was identified with the researcher observing that there was less adherence to the approach without this leadership (The Learning Disabilities Elf, 2014). However, Schriivers, van Hoore and Huiskes (2012) argue that a disadvantage to the care pathway is the decline of diversity within professional work and how they may cause professionals to rely too much on a specific routine, because they are working within a single care pathway, always seeing the same groups of patients, there is a chance of increasing indifference, cynicism and reduced empathy with the patient. Whilst a review carried out by Cabana et al. (1999) categorised barriers as relating to clinician attitudes, knowledge and behaviour, with knowledge related barriers resulting from lack of awareness and familiarity. There are studies which have established knowledge gaps amongst clinicians in following the publication of guidelines (Eaton et al., 2006) though modifying documentation or wording has been found to make them more user friendly (Michie and Johnston, 2004). Attitude related barriers may relate to clinicians being unconvinced of the rationale for the pathway implementation, such as perceiving pathways to be driven by reasons relating to management or cost containment rather than their use as a decision supporting tool (Formoso, Liberati and Magrini, 2001). While evidence shows that care pathways are essential in improving treatment quality of healthcare services, one of the main challenges of implementing care pathways is treatment personalisation, inadequate dynamic adaptability restricts the practicality of care pathways (Hua-Qiong et al., 2013). Schriivers, van Hoore and Huiskes (2012) also mention that the care pathways ensure a less personal relationship between the health professional and the patient, reducing the patient’s choices, and the quality of car may be compromised by the maximum time restraints for each patient.
Evidence consistently shows the importance of patient involvement in their own healthcare decision making which not only empowers the patient but also improves treatment and service outcomes, it has also become a political necessity in many countries (Vahdat et al. 2014). However, a review by the Care Quality Commission (2016) found that there are certain groups who are much less involved with their own care than others, including people with a learning disability and people over the age of 75. Recommendations suggested by the CQC within this review included service providers personalising care plans, written with the patient and clearly identifying their preferences and wishes, the coordination of the patient’s involvement in their care as they move between services and also sustained and supported involvement of families and carers of the patient.
Nursing is an extremely challenging and dynamic profession, one which requires inspiring and engaging role models and leaders. Identifying and developing nurse leaders can be one of the greatest challenges faced by the nursing profession however, it is a vital aspect in todays demanding and ever changing healthcare system (Scully, 2015). The concept of leadership is a complex and multi-dimensional phenomenon and while there has been research conducted for over a century which concludes that although it is one of the most observed concepts, there is no universally accepted definition of leadership (Atsalos and Greenwood, 2001). Some recent theories of leadership, which combine aspects of both situational and personal trait theories, recognise that effective leadership depends on the personality of the leader, the situation at hand and the qualities of the followers. Leadership is not a haphazard occurrence, it involves vision, communicating that vision to others, planning to make it a reality whilst serving as a symbol and source of energy for the team (Grossman and Valiga, 2012). In the clinical practice environment, leadership is essential to ensure both positive patient outcomes and successive generations of enthusiastic and motivated clinicians (Davidson, Elliott and Daly, 2006). There are many different identified styles of leadership, however transformational leadership and transactional leadership are among two of the most common (Sfantou et al. 2017). Typically, transformational leaders have the ability to inspire confidence and staff respect and they communicate loyalty through a shared vision which results in an increase in productivity and strengthens both employee morale and job satisfaction (Burns, 1978). Transformational leaders, however, tend to come up with extreme ideas in order to achieve outlandish dreams, tending to focus on the big picture whilst overlooking the smaller details required to achieve the goal. This lack of transactional focus is one of the biggest weaknesses of the transformational leader (Brandon Gaille, 2018). In transactional leadership, the leader in question acts as a manager of change, making changes with their employees that lead to improvements in production (Burns, 1978). These leaders are focused on short term goals, procedures, rules, standards and control and work on the assumption that their employees are motivated by a reward and punishment system (Nikezić, Purić and Purić, 2012). One disadvantage of the transactional leader is that they are quite rigid in their expectations about the working relationship and believe it is the role of their followers to do as they are told, using their formal authority to instruct on what to do and unwilling to consider anything other than traditional organisational hierarchy. Their over reliance on this single approach and unwillingness to consider the ideas of other, limits the leader’s creativity and ability to adjust if things go wrong (Chron, 2019).
The NHS leadership framework represents the foundation of leadership that all staff should aspire to. The framework provides a consistent approach to leadership development for staff in healthcare regardless of role, discipline or function (NHS Leadership Academy, 2011). An essential aspect of its development was to create a single overarching leadership framework for all healthcare staff based on the concept that it is not restricted to people who hold designated leadership roles and where there is a shared responsibility for the success of the organisation, services or care being delivered (NHS Leadership Academy, 2011). Acts of leadership can be carried out by anyone within the organisation and as a model it highlights the responsibility of all staff to demonstrate appropriate behaviours in seeking to contribute to the leadership process and to develop and empower the leadership capacity of their colleagues (NHS, Institute for Innovation and Improvement, 2009). Delivering services to the public, service users, patients and carers is at the heart of the leadership framework. The needs of people who use services is what is central to healthcare and staff are constantly working hard to improve services for them and in doing so staff must be competent in the five core leadership domains: Improving services, effective leadership requires individuals to make a difference to people’s health by delivering high quality service and developing improvements to services. Managing services, this requires individuals to focus on the success of the organisation in which they work. Working with others which involves demonstrating personal qualities which involves individuals to draw upon their own strengths, abilities and values to deliver high standards of care and also setting direction in which effective leadership requires individuals to contribute to the strategy and aspirations of the organisation and act in a manner which is consistent with its values. There are two other domains of the leadership framework, creating the vision and delivering the strategy, however, these focus more on the role and contribution of individual leaders, particularly those in senior positions (NHS Leadership Academy, 2011).
The term ‘dementia’ is a descriptive term that is derived from the Latin root de mens, it indicates a visible decline in mental abilities. It is an acquired clinical syndrome which is characterised by deterioration of mental functioning in its cognitive, emotional and conative aspects (Gustafson, 1996). In the UK alone, there are currently 850,000 people living with dementia, with number set to rise to over 1 million by the year 2025, soaring to 2 million by 2051. There are currently 1 in 6 people over the age of 80 living with dementia and 70% of people living in care homes have dementia or severe memory problems (Alzheimer’s Society, 2019). Globally, it is estimated that there around 46.8 million people living with dementia and the number affected will double every 20 years, rising to 115.4 million by the year 2050 (Samsi and Manthorpe, 2014). Another 7.7 million people will develop dementia globally every year (Alzheimer’s, 2019). In the UK alone, the cost of dementia is currently at £26 billion a year, or an average annual cost of £32,250 per person. Two-thirds of this cost is currently being paid for by people with dementia and their families, either by paying for private social care, or in unpaid care (£11.6 billion). For a person with dementia, the cost of a care home can be between £600-1,200 a week, with good quality care in the home costing at least £20 per hour (Alzheimer’s society, 2019). As a consequence of rising numbers and costs, governments have expressed their commitment to sharing systematic approaches to the prevention, diagnosis and treatment of dementia with national plans developed to achieve national specific aims (Samsi and Manthorpe, 2014). At an international level, the World Dementia Council was launched in 2014 which aims to change the lives of people living with dementia by securing change internationally, working with international governments and non-government organisations (World Dementia Council, 2018). There is currently no cure for dementia, therefore the focus of treatments is to slow down the progression of the disease and to improve the quality of life for the person.
Garrard (2013, p. 4) defined the literature review as “reading, analysing and writing a synthesis of scholarly materials about a specific topic”. The process of literature searching may sound daunting for many student nurses however, the practice of nursing depends on continually evolving scientific knowledge reported in the literature that informs the critical thinking, decision making processes that nurses participate in every day (American Nurses Association, 2010). Therefore, it is crucial that nurses appreciate the importance of literature reviews and how to conduct them effectively (Bernhofer, 2015). Commencing on a research project is the most commonly understood reason for conducting a literature review. Research uses the steps of the scientific method to conduct a systematic, rigorous, investigation to answer questions and contribute to the knowledge of the science that will be useful for practice (LoBiondo- Wood and Haber, 2013). A combination of current, relevant published literature provides the most current published information necessary so that the investigators time and money are not spent wasted on questions that have already been discovered (Bernhofer, 2015). The first stage of evidence based practice is to formulate the research question; this can also be the most challenging stage of the process (Rowles and McNaughton, 2017). Bordage and Dawson (2003) have also argued that the research question is the single most important component of a study. Taking the time to formulate a clearly worded and detailed question is important as these are the words that will typically be used when performing the literature search therefore the more detailed the question is, the more likely that the answer will be found (Johnson, 2008). Cluett (2002) suggests using the acronym PICO which stands for P- patient or population, I – issue or intervention, C – comparison and O – outcome. The literature search begins by putting key words from the PICO list together in different combinations and using this to explore. The PICO framework is considered a widely known strategy for framing a foreground research question (Aslam and Emmanuel, 2010). The purpose of this assignment is to look at family or caregivers (population) experiences (outcome) of music therapy (intervention) in dementia care. Due to the framework breaking the question into four components, this facilitates the identification of the relevant information (Sackett et al., 1997). There are different techniques for using key words for online literature searches. One of these techniques is called Boolean and this involves the method of using “and”, “or” and “not” between each keyword in order to make a search more narrow or broad (Jaffe and Cowell, 2014). There are many commonly used search-engines available online including PubMed and google scholar, however the search engine that will be used for this assignment will be the Cumulative Index to Nursing and Allied Health Literature (CINAHL) through EBSCO, due to the CINAHL databases being the most widely used and respected research tools for nurses, students and allied health professionals alike (EBSCO Nursing Resources, 2019).
For the purpose of this research three papers were used (Appendix 1, 2 and 3) which will be referred to as paper 1, 2 and 3. As the titles suggests, the studies were all researching family and carers experiences and perspectives of music therapy caregiving for people with dementia. Evidence has found that music therapy may be beneficial in treating or managing dementia symptoms and it has been highlighted that better designed studies of this intervention are required (Koger and Brotons, 2000). To establish the credibility of a study, researchers should use rigorous methods and techniques in order to gather high quality data which is carefully analysed, with attention to validity, reliability and triangulation (Patton, 1992). The most common type of triangulation is methodological triangulation. Studies that use triangulation may include two or more sets of data collection using the same methodology, such as from qualitative data sources. This approach allows the limitations from each method to be transcended by comparing the findings from different perspectives (Williamson, 2005).
Gaining informed consent is a legal and ethical requirement for any research involving human participants, that is to say they will be informed about all aspects of the study, which is important for the participant to study all aspects of said trial and therefore make a decision confirming their willingness to participate. This is also an important aspect for the research to make an advancement of medical knowledge and social welfare (Nijhawan et al., 2013). Paper 1 mentions that the study was approved by a regional ethics committee, in accordance with Swedish law (CODEX rules and guidelines for research, 2018), however, does not mention individual participant consent. The NMC code of conduct states that consent must be gained before any treatment or care begins and that for any person for whom mental capacity may be an issue they must remain at the heart of the decision making process and be fully safeguarded (Nursing and Midwifery Council, 2015). Paper 2 mentions that ethics approval was granted by the National Research Ethics Service and that where possible consent was sought from the participants themselves, and also states that some residents needed second consent from family or carers in line with the Mental Capacity Act (2005). Paper 3 does not mention the issue of consent, as gaining consent is one of the most important ethical rules of a qualitative study (USC Libraries, 2019) it is important that this issue is addressed.
There are many different types of dementia which will affect people in different ways, with each person experiencing symptoms in their own way (NHS Dementia guide, 2017) and with the number of people with dementia on the increase due to people living longer with Alzheimer’s society estimating there are now around 850,000 people in the UK alone (Alzheimer’s Society, 2019). The small sample sizes of the papers: Paper 1 (10 people with dementia and 6 caregivers) Paper 2 (16 people with dementia and 29 care staff) and paper 3 (23 care staff) cannot be generalised to all people with dementia. When researchers find themselves constrained to a small sample size due to logistical or economic issues, they may have to settle for less conclusive results (Sciencing, 2018). However, Studies with a small sample size can be quicker and easier to conduct in regard to selecting participants, asking participants to complete questionnaires or reviewing patient records, hence making studies with a smaller sample size possible to execute over a shorter space of time (Hackshaw, 2008). the UK two thirds of people with dementia are living in the community in their own homes while one third are living in care homes (Social Care Institute for Excellence, 2015). As the three studies were conducted within care homes this again cannot be generalised to all people with dementia as behaviours in care homes can differ due to many factors (Alzheimer’s Society, 2007).
Confirmability of a study refers to the degree of which the results could be confirmed or corroborated by other researchers (Baxter and Eyles, 1997). It is concerned with establishing that the data and interpretations of the findings are not just a figment of the researcher’s imagination but are clearly derived from the data (Tobin and Begley, 2004). Trustworthiness was increased in paper 1 by performing the analysis in cooperation with the researchers of the study. The first researcher and the last researcher of the study compared and discussed the steps of the analysis and within this discussion, agreements and disagreements emerged, when disagreements emerged the issues were discussed with the other researchers of the study, who also audited the analysis process until agreements were reached within the group. The manuscript was also critically discussed in a scientific group, with the transcribed text of the interviews, as well as the findings, taken back to the caregivers involved in the study for confirmation.